Source · Prevention of Future Deaths
Stephen Beadman
Ref: 2023-0210
Date: 23 Jun 2023
Coroner: Kevin McLoughlin
Area: West Yorkshire (Eastern)
Responses identified: 0 / 3
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A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short of "equivalence of care" and risking insufficient specialist support for long-term inmates.
Date
23 Jun 2023
56-day deadline
2 Sep 2023
Responses identified
0 of 3
Coroner's concerns
A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short of "equivalence of care" and risking insufficient specialist support for long-term inmates.
View full coroner's concerns
1) Evidence was taken at the Inquest to the effect that HM Prison, Wakefield is a maximum-security prison which houses some 750 men, many of whom have significant mental health or addiction issues.
2) Despite this complex cohort of prisoners, the prison only has one day per week of consultant psychiatrist resource. As the professed principle is equivalence of care with the community, this seems not to be achieved, particularly having regard to the psychological make up of the prisoner population.
3) Evidence taken at the Inquest indicated that further senior psychiatric doctor resource would enable the prison to provide better for the needs of the prisoners.
4) For the avoidance of doubt, it is accepted that Mr Beadman himself was able to see the consultant psychiatrist on 19th October 2021 for 1 hour and again on 25th January 2021 (at which time he was discharged). Notwithstanding that his death on 8th April 2021 cannot be attributed to a lack of psychiatric attention, there is a concern that other long-term inmates in the prison are not receiving the specialist care they probably need. This in turn gives rise to a concern that other deaths may occur.
5) The Inquest was informed that NHS England are currently reviewing the provision of psychiatric resource at HM Prison, Wakefield. It is hoped that this report can be taken into account during this review.
2) Despite this complex cohort of prisoners, the prison only has one day per week of consultant psychiatrist resource. As the professed principle is equivalence of care with the community, this seems not to be achieved, particularly having regard to the psychological make up of the prisoner population.
3) Evidence taken at the Inquest indicated that further senior psychiatric doctor resource would enable the prison to provide better for the needs of the prisoners.
4) For the avoidance of doubt, it is accepted that Mr Beadman himself was able to see the consultant psychiatrist on 19th October 2021 for 1 hour and again on 25th January 2021 (at which time he was discharged). Notwithstanding that his death on 8th April 2021 cannot be attributed to a lack of psychiatric attention, there is a concern that other long-term inmates in the prison are not receiving the specialist care they probably need. This in turn gives rise to a concern that other deaths may occur.
5) The Inquest was informed that NHS England are currently reviewing the provision of psychiatric resource at HM Prison, Wakefield. It is hoped that this report can be taken into account during this review.
Report sections
Investigation and inquest
On 20th April 2021 I commenced an investigation into the death of Stephen Kurt Beadman, aged 34. The investigation concluded at the end of the Inquest on 21st June 2023. The conclusion of the Inquest was a Narrative which included a finding that Mr Beadman committed suicide having been bullied by other prisoners.
Circumstances of the death
Mr Beadman, aged 34, was a serving prisoner at HMP Wakefield. He had been diagnosed with a mixed personality disorder along with mixed depression and anxiety. He was prescribed medication. He had a long history of self-harm and in 2020-21 repeated suicide attempts. On 7th April 2021 he was found in an unresponsive state having applied a ligature to his neck. He died the following day, 8th April 2021 in hospital from:
1(a) Hypoxic Ischaemic Encephalopathy 1(b) Cardiac Arrest 1(c) Hanging
1(a) Hypoxic Ischaemic Encephalopathy 1(b) Cardiac Arrest 1(c) Hanging
Copies sent to
3) , Governor, HMP Wakefield4) Practice Plus Group1) , Consultant Psychiatrist2) , Government Legal Department3) , Governor, HMP Wakefield4) , Nottingham University
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Report details
- Reference
- 2023-0210
- Date of report
- 23 June 2023
- Coroner
- Kevin McLoughlin
- Coroner area
- West Yorkshire (Eastern)
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Sep 2023.
Sent to
- HM Prison Wakefield
- Ministry of Justice
- NHS England